Use$of$the$Segway$During$ Physical$Therapy$for$ …iss.pitt.edu/iss2015/ISS2015Handouts/PS5.3_Handouts.pdf · Use$of$the$Segway$During$ Physical$Therapy$for$ Postural$Control$and$Balance$

Use$of$the$Segway$During$Physical$Therapy$for$

Postural$Control$and$Balance$Training$for$Pediatric$and$Adolescent$Patients$with$

Cerebral$Palsy!

31st%International%Seating%Symposium%2015%February%27,%2015%(PS5.3)%

Matthew$K.$Luginbuhl,$PT!!

PediaBlex$Therapy$Center,$LLC.$$Wethers'ield,,CT,,,

%www.PediaAlex.com/staff%[email protected]%

%%

Disclosure:%Mr.%Luginbuhl%is%the%owner%of%PediaAlex%Therapy%Center,%LLC.$%

2!PediaFlex!Therapy!Center,!LLC!!5!!2015!!!!!!!!!!!!!!!!!!31st!Interna<onal!Sea<ng!Symposium!

OBJECTIVE!

Clinical%Review%–%Kids%with%CP%received%training%on%a%Segway%as%part%of%their%PT%plan%of%care%to%improve%postural%control%and%

balance.!


LEARNING$OBJECTIVES!1.  Describe%three%inclusion$considerations$for%

use%of%a%Segway%in%a%peds%PT%clinic.%%

2.  Describe%three%safety$concerns$when%using%a%Segway%for%PT%treatment.%%

3.  List%three%treatment$activities$to%provide%balance%training%for%children%with%CP.%

4.  List%three%outcomes$expected$when%using%a%Segway%for%kids%with%CP.%


Few%activities%simultaneously%challenge%the%perceptual%challenges%of%movement%through%space%and%postural%motor%components%of%

balance%in%standing.%%%


The%Segway%was%chosen%to%increase%the%kid’s%interest%and%duration%of%practice%of%postural%control%and%

balance%activities.%%%%%


The%body%maintains%postural%stability,%in%response%to%environmental%changes%and%

intended%interactions%and%tasks.%%%7!PediaFlex!Therapy!Center,!LLC!!5!!2015!!!!!!!!!!!!!!!!!!

31st!Interna<onal!Sea<ng!Symposium!

INITIAL&WORK&WITH&SEGWAY&IN&PT&Sawatzky,!Denison!et!al.!illustrated!in!2007!that!the!Segway!is!a!useful!device!for!pa<ents!with!a!variety!of!func<onal!disabili<es.!!Their!study!had!23!par<cipants!ranging!in!age!from!19!to!65!years!old.!!!!Par<cipants!used!a!variety!of!mobility!aides,!including!prostheses,!manual!wheelchairs,!canes,!forearm!crutches,!walkers,!ankle!and!knee!braces,!and!scooters.2!!!Sawatzkuy,!Denison,!and!Tawashy!followed!up!their!ini<al!pilot!study!with!a!second!study!further!demonstra<ng!that!the!Segway!may!be!a!good!mobility!aid!for!people!with!disabili<es.!!They!discuss!that!the!Segway!can!provide!an!alterna<ve!mobility!aide!to!op<mize!their!func<onal!op<ons!in!life!recrea<onally,!in!response!to!disability!progression,!and!to!meet!their!individual!mobility!goals.3!!On!an!impairment!level,!Bou<lier,!Sawatzky,!et!al.!found!that!use!of!a!Segway!can!reduce!spas<city,!decrease!pain!and!decrease!fa<gue!on!a!short5term!basis.4!!!

PediaFlex!Therapy!Center,!LLC!!5!!2015!!!!!!!!!!!!!!!!!!31st!Interna<onal!Sea<ng!Symposium! 8!

PARTICIPANTS&

Who!were!the!kids!that!used!the!Segway?!


17$Kids$with$CP$

6%girls%

6%to%17%years%old%

Variety%of%past%medical%history%consistent%with%the%diagnosis%of%CP%and%individual%GMFCS%Levels%

Variety%of%uses%of%orthotic%supports%and%mobility%devices.%%%%%

Hemiparesis$4%at%Level%1!

Diplegia$1%at%level%1%2%at%level%3%!

Tripegia$2%at%level%3!

Quadriplegia$2%at%level%4%2%at%level%5!

Athetosis$1%at%level%1%1%at%level%3%2%at%level%4%!

11%boys%

“level”&=&GMFCS&Level&


%The%LeanSteer$frame$and$handlebar$tilt%left%and%right%in%response%to%the%body’s%natural%inclination%to%lean%in%the%direction%of%intended%travel.%%%The%wireless$InfoKey$controller$constantly%monitors%data%such%as%battery%level,%speed%and%distance,%and%has%security%features.%It%can%set%limitation%on%speed%from%4%to%12%mph%and%has%a%“Turtle%Mode”%speed%setting.%%

THE$SEGWAY$I2$SE$$


THE$SEGWAY,$MODEL$i2$SE$&


PRECAUTIONS$AND$SAFETY!•  Initial$Wobble$Precaution%%%•  Controlling%Creep%Precaution%%•  Curb%Cut%Precaution%%%•  Ice%and%Sand%Precaution%%•  Pet%Precaution%%•  “I%Can’t%Stop”%Precaution%%•  Racing%Precaution%%•  Bicycle%Helmet%And%Gait%Belt%%•  Mobile%Cellular%Phone%%•  Watch%For%Vehicle%TrafAic%%%•  Individual%case]by]case%contingency%planning%for%fatigue,%behavior,%psychomotor%readiness,%and%seizures%


PRECAUTIONS$AND$SAFETY%!•  Initial%Wobble%Precaution%•  Controlling$Creep$Precaution%%•  Curb%Cut%Precaution%•  Ice%and%Sand%Precaution%•  Pet%Precaution%•  “I%Can’t%Stop”%Precaution%•  Racing%Precaution%•  bicycle%helmet%and%gait%belt%•  mobile%cellular%phone%%•  Watch%for%vehicle%trafAic%•  Individual%case]by]case%contingency%planning%for%fatigue,%behavior,%psychomotor%readiness,%and%seizures%


Video&of&Controlling&Creep&PrecauGon&


PRECAUTIONS$AND$SAFETY%!•  Initial%Wobble%Precaution%•  Controlling%Creep%Precaution%•  Curb%Cut%Precaution%%•  Ice%and%Sand%Precaution%%•  Pet%Precaution%•  “I%Can’t%Stop”%Precaution%•  Racing%Precaution%•  bicycle%helmet%and%gait%belt%•  mobile%cellular%phone%%•  Watch%for%vehicle%trafAic%%•  Individual%case]by]case%contingency$planning$for%fatigue,%behavior,%psychomotor%readiness,%and%seizure%


VIDEO&CONTINGENCY&PLANNING&I&SEIZURES&


PREWTRAINING$$W$To$help$determine…!

•  Standing%balance%with%two%hands%on%a%bar%%

•  Levels%of%assistance%%

•  Standing%endurance%%

•  Safety%planning%

•  Psychomotor%learning%needs%%

•  Postural%control%%%


PREWTRAINING$ACTIVITIES&•  Sit]to]stand%weight%bearing%with%ladder%support%in%front%•  Use%of%uni]directional%and%multi]directional%wobble$board$in%standing%with%ladder%support%in%front%

•  Tolerance%for%static%standing%in%standing%frame%with%decreasing%support$

•  Use%of%Lateral$Thigh$Trainer®$with%ladder%support%in%front%

•  Gait$training$with%walker%or%gait%trainer%•  Use%of%LiteGait®%with%ladder%support%in%front%and%decreasing%vertical%lift%assistance%(body%weight%support)%

•  Platform%%glide$swing$$$•  Curb%and%step$training$


Video&of&PreITreatment&Examples&


VIDEO!SPEED!SET!AT!200%!

ASSISTANCE$NEED$TO$GET$ON$AND$OFF$THE$SEGWAY!•  Patients%that%were%ambulatory%–%Assist$of$one$holding%the%Segway%handle%bar%and%stabilizing%its%movement.%%Patient%is%cued%to%step%up%like%their%stepping%up%onto%a%step.%%Patient%is%encouraged%to%hold%the%Segway%handle%bar%before%stepping%up.%

•  Patients%that%could%not%stand%or%walk%independently%]%Assist$of$two$with%one%holding%Segway%stable%while%the%other%assists%the%patient%to%step%up%and%on.%%Patient%is%encouraged%to%hold%the%Segway%handle%bar%before%stepping%up.%

•  Patients%that%required%knee%immobilizers%%]%Patient%is%lifted%on%with%appropriate%assistance.%%Patient%is%encouraged%to%hold%the%handle%bar%as%they%stand%on%the%Segway.%


Video&of&MounGng&the&Segway&


LEVELS$OF$ASSISTANCE$WHILE$USING$THE$SEGWAY!•  Independent:%No%patient%was%allowed%to%use%the%Segway%on%their%own%%•  Close$And$Distant$Supervision:%%Therapist%within%5%to%15%feet%of%the%

patient%at%all%times%

•  Slight$Assistance:%Contact%guard;%verbal%cues%

•  Minimal$Assistance:%Assist%of%one;%use%of%Theratogs®,%Spio®:%use%of%grip%assist%%

•  Moderate$Assistance:%Assist%of%one%or%two;%use%of%Theratogs®,%Spio®,%knee%immobilizers,%grip%assist%%

•  Maximum$Assistance:%%Assist%of%two%or%three;%use%of%Theratogs®,%Spio®,%knee%and/or%elbow%immobilizers,%grip%assist%%

•  Total$Assistance:$$No%patient%was%allowed%to%use%the%Segway%if%they%could%not%bear%weight%through%their%legs%


TREATMENT$ACTIVITIES!

•  SpeciBic$courses$set$up$with$cones.$$

%•  Patient%self]selected%destination%%

•  Indoor%and%outdoor%general%exploration%and%movement%around%the%environment.%%%

%


Barrel!Race!


Weaving!Around!Cones!


¶!Barrel&Race&Phase&1&

•  Over!shoots!!•  Poor!decelera<on!•  Runs!over!cones!•  Misses!cones!!



•  Improving!•  Runs!over!

targets!•  Gets!all!cones!!



•  Tighter!turns!•  Hits!one!cone!•  Faster!!


Video&of&Barrel&Race&and&Cone&Weaving&


VIDEO!SPEED!SET!AT!200%!

TREATMENT$ACTIVITIES!•  SpeciAic%courses%set%up%with%cones.%%%•  Patient$selfWselected$destination$$$•  Indoor%and%outdoor%general%exploration%and%movement%around%the%environment.%%%

%


Picture&of&Wethersfield&Creamery&


TREATMENT$ACTIVITIES!•  SpeciAic%courses%set%up%with%cones.%%%•  Patient%self]selected%destination%%

•  Indoor$and$outdoor$general$exploration$and$movement$around$the$environment.$$$

%


CLINICAL$OUTCOMES!

•  “Improved%motivation”%%•  “Greater%patient%participation”%%•  “Increased%duration%of%practice”%%•  “Decreasing%levels%of%assistance”%%%•  “Access%to%community%based%activities”%%


PATIENT&ACHIEVEMENT&TOWARD&LESS&ASSIST&OVER&TIME!!


EXAMPLE&OF&PATIENT&LEARNING&POSTURAL&CONTROL&AND&BALANCE&OVER&TIME.&•  Pa<ent!number:!15!•  Prac<ce!started!March!21,!2013!•  Gained!balance!for!close!supervision!!!!!!!!!!!!!!!on!June!10,!2013!

•  Total!treatments:!12!(one!hour!sessions)!•  Frequency!of!Visits:!1x/week!•  Total!Dura<on:!12!weeks!!


Video&Learning&Postural&Control&on&Segway&over&Gme&


EXAMPLE&OF&PATIENT&LEARNING&POSTURAL&CONTROL&AND&BALANCE&OVER&TIME.&•  Pa<ent!number:!17!•  Prac<ce!started!Oct.!28,!2009!•  Gained!balance!for!close!supervision!!!!!!!!!!!!!!!on!April!15,!2010!

•  Total!treatments:!37!(1!to!2!hour!sessions)!•  Frequency!of!Visits:!2x/week!•  Total!Dura<on:!24!weeks!!


Video&Before&and&AYer&15&and&17&


Steering%%%%%%%%!

Acceleration%!

Deceleration!

Stepping%up%and%down!

Judging%distances!

Hands%and%upper%body%to%maintain%balance%!

Improved%handwriting%!

Greater%hand%and%Ainger%control%on%AAC%device!

Exposure%to%socialization%and%peer%interaction%opportunities!

OUTCOMES&


A&quick&note&about&the&end&of&the&next&video…&•  This!pa<ent!had!improved!handwri<ng!skills!•  The!video!shoes!her!playing!me!at!<c5tac5toe.!•  Then!it!shows!her!work!samples!over!<me!– Base!Line!Oct,!2009!– Aber!Segway!Work!Feb,!2011!– Aber!more!Segway!Work!May,!2011!

&OUTCOME:&Much&Improved&control&of&markings&on&paper!&


Video&of&Outcomes&


Can&you&spot&the&kid&that&is…&

…happy!!!…happy,!too!!!…stronger!!!…using!her!vision,!despite!being!blind!in!one!eye!!!…can!make!a!figure!8!driving!with!his!weak!hand!!!…hanging!out!with!his!buddies!!!…standing!at!the!table!wai<ng!for!his!mom!!!

…has!a!happy!SLP!because!of!stronger!hands!for!AAC!use!!!…is!doing!cool!things!with!his!friend!!!…s<ll!trying!to!beat!me!at!<c5tac5toe!!

OUTSIDE$OF$THE$CLINIC$IN$THE$COMMUNITY$SETTINGS&•  School%]%general%daily%mobility%•  University%]%general%daily%mobility$•  Home%program%]%general%neighborhood%exploration%outings%•  Bat%mitzvah%celebration%event%•  Field%day%event%]%7th%graders%•  Physical%education%class%]%participation%in%a%baseball%game%•  walkathon%fundraiser%•  AAC/AT%Summer%Camp%to%access%communication%stations%•  Community%recreational%Aields%]%baseball%diamond,%accessible%ramped]playscapes%

•  neighborhood%streets%and%backyard%play%areas%•  Before%school%exercise%program%]%in%a%gymnasium%environment.%%


Video&of&Community&Access&Outcomes&


DISCUSSION&

So…What!are!some!things!that!might!be!going!on?!


DISCUSSION&&“FeedWBack”$Postural$Responses…$

•  Motor%output%triggered%by%sensory%input%•  Example:%suspensory%postural%reactions%to%negotiation%of%bumpy%surfaces%

…subconscious$control$without$purposeful$reactions$to$environmental$changes.41543!$


Saxena!et!al.,!Haas!e!t!al.,!Hirschfeld!and!Farssberg!

DISCUSSION&&“FeedWForward”$Postural$Adjustments$…$

•  Responses%to%intended%interactions%and%tasks%to%keep%the%body’s%COM%over%its%BOS%for%static%and%dynamic%equilibrium%

•  Example:%control%of%acceleration,%deceleration,%and%directionality%by%adjusting%the%body’s%posture%and%lean%on%the%Segway%moving%toward%and%around%the%environment%or%in%the%direction%of%intended%destination%

…intentional$movements$as$anticipatory$postural$control.11,!44546!$


Woollacof!and!Shumway5Cook,!Burleigh!et!al.,!Hirschfeld!and!Forssberg,!!Riach!and!Hayes!

Gradually$the$patients$would$$learn$how$to$anticipate$distance$

speed$and$turning$radius$$and$make$adjustments$to$their$posture$to$control$the$Segway$

$to$interact$with$their$environment$and$intended$mobility$goal.!47!$&


Maki!and!McIlray!

DISCUSSION&&Other%possible%things%happening:%•  Kandel%et%al.%found%that%vision%provides$information$about%the%environments%vertical$alignment$and%the%body’s$motion$relative$to$the$environment,%giving%information%about%when%the$body$will$make$contact$with%objects%in%the%environment.48%%

•  When%studying%the%fear%of%falling,%and%its%relationship%to%balance%control,%Carpenter%et%al.%noted%that%stimuli$to$the$vestibular$system$may%evoke%postural$reBlexes$inherent%in%balance.49%%

•  Peterka%discussed%that%the%vestibular%system%is%thought%to%detect%deviation%of%head%orientation%with%respect%to%the%Aield%of%gravity,%called%the%graviceptive$signal.50%%Vestibular%sensory%signals%are%considered%to%be%the%primary%contributor%to%graviception.51%%


DISCUSSION&&

Interventions%that%span%%the%health%condition,%the%impairment,%%

the%activity%limitations,%%and%participation%restrictions%%

are%rare,%%but%when%found%encompass%the%whole%“biopsychosocial”%model.52%ICF%%


DISCUSSION&&

Clinic%based%treatment%activities%often%fall%short%of%satisfying%both%“performance”%and%“capacity”%qualiAiers,%due%to%the%clinic%not%representing%real%home%or%community%environment;%or%the%home%not%providing%impairment%level%modalities%of%care.52%%ICF%


“capacity!qualifier!describes!an!individual’s!ability!to!execute!a!task!or!an!ac<on”!!“the!performance!qualifier!describes!what!an!individual!does!in!his!or!her!current!environment!“!

DISCUSSION&&Six%of%the%patients%in%this%clinical%review,%that%were%able%to%use%the%Segway%in%the%clinic%for%postural%control%and%balance,%had%strong%interest%in%gaining%access%to%its%use%in%the%

community…%%…a%good%demonstration%of%bridging%the%beneAits%of%gained%postural%control%for%standing%mobility,%and%improved%efAicient%access%to%activity%and%

recreation%participation.52!


CLINICAL!REVIEW!LIMITATIONS!•  As!a!clinical!review,!biases!are!present.!!!•  As!a!single!site!study!we!were!only!sampling!one!clinics!experience!resul<ng!in!bias.!!

•  Pa<ents!were!self5selected!from!our!limited!pa<ent!caseload!and!there!may!be!others!that!could!benefit!from!its!use.!!!

•  There!is!a!lack!of!specific!assessment!tools!for!pre5post!comparison.!!

!(Timed5Up5and5Go5Test!(TUG)53555;!Pediatric!Balance!Scale56;!p0ediatric!and!pa<ent!and!family!!

ques<onaires57559;!GMFM60;!segmental!assessment!of!trunk!control!(SATCo)61,!62;!WeeFIM63,!64;!or!Early!Clinical!Assessment!of!Balance!(ECAB).65)!


CONCLUSION!•  This%clinical%review%supports%the%use%of%a%Segway%for%

treatment%of%young%patients%with%CP%during%PT%for%the%treatment%of%postural%control%and%balance.%%%

•  This%clinical%review%also%suggests%that%the%Segway%can%be%used%in%a%variety%of%community%settings%and%situations%to%assist%mobility%for%children%and%adolescents%with%CP.%%

•  Further%research%is%needed%to%better%understand%how%the%Segway%affects%patients%with%postural%control%and%balance%deAicits%due%to%CP.%%%

•  Further%research%is%needed%to%better%understand%the%clinical%and%community%outcomes%gained%from%the%use%of%the%Segway%during%PT.%%%

•  This%clinical%review%is%a%good%example%of%the%links%needed%between%real]world%clinical%treatment%environments%and%the%research%setting%references.66570!%%%


THANK$YOU$$for$attending$$

my$presentation!&


! 1!

Use$of$the$Segway$During$Physical$Therapy$for$Postural$Control$and$Balance$Training$For$Pediatric$and$

Adolescent$Patients$with$Cerebral$Palsy$$

31st%International%Seating%Symposium%%Nashville,%TN%Presentation:%February%27,%2015%(PS5.3)%

!!!Matthew$K.$Luginbuhl,$PT,!Owner!of!Pediaflex!Therapy!Center,!LLC!Wethersfield,!CT,[email protected]!For!Background!Information!visit!www.Pediaflex.com/staff!!Disclosure:!Mr.!Luginbuhl!is!the!owner!of!Pediaflex!Therapy!Center,!LLC!$Learning$Objectives:$$

• Describe! three! inclusion! considerations! for! use! of! a! Segway! in! a! pediatric!physical!therapy!clinic.!!

• Describe! three! safety! concerns! when! using! a! Segway! for! physical! therapy!treatment.!!

• List! three! treatment!activities! to!provide!balance! training! for! children!with!cerebral!palsy.!

• List!three!expected!outcomes!when!using!a!Segway!for!children!with!cerebral!palsy.!

$Objective:$Clinical!Review!–!Pediatric!and!adolescent!patients!with!cerebral!palsy!(CP)!received!training!on!a!Segway!™!Personal!Transporter!(Segway)!as!part!of!their!physical! therapy! (PT)! plan! of! care! to! improve! postural! control! and! balance.! !This!clinical! review! describes! patient! inclusion! considerations,! safety! concerns,!treatments,! and! outcomes! for! children! and! adolescents! with! CP! that! used! the!Segway!during!PT!for!postural!control!and!balance.!!$Background:!$The! Segway! is! a! two!wheel! electric!motorized! selfRbalancing! device! that! the! user!stands!on!to!get!around.!!The!Segway!i2!SE!Model,!has!a!central!post!and!handle!bar!steering! system! that! responds! to! the! users! leaning.! ! The! Segway! uses! internal!sensors! and! gyroscopes! for! balance! and!mobility.! ! The! Segway!moves! in! order! to!maintain!its!balance!when!it!is!typed!out!of!balance.1!!!!Sawatzky,!Denison!et! al.! illustrated! in!2007! that! the!Segway! is! a!useful!device! for!patients!with! a! variety! of! functional! disabilities.! ! Their! study! had! 23! participants!ranging! in! age! from!19! to! 65! years! old.! ! ! ! Participants! used! a! variety! of!mobility!aides,! including!prostheses,!manual!wheelchairs,!canes,! forearm!crutches,!walkers,!ankle!and!knee!braces,!and!scooters.2!!

Use$of$the$Segway$During$Physical$Therapy$for$Postural$Control$and$Balance$$Training$for$Pediatric$and$Adolescent$Patients$with$Cerebral$Palsy,$Matthew$Luginbuhl,$PT$

$Pediaflex$Therapy$Center,$LLC$$$$31st$International$Seating$Symposium$2015$–$Nashville,$TN$

!

2$

!Sawatzkuy,!Denison,!and!Tawashy!followed!up!their!initial!pilot!study!with!a!second!study!further!demonstrating!that!the!Segway!may!be!a!good!mobility!aid!for!people!with!disabilities.!!They!discuss!that!the!Segway!can!provide!an!alternative!mobility!aide! to! optimize! their! functional! options! in! life! recreationally,! in! response! to!disability! progression,! and! to! meet! their! individual! mobility! goals.3!!On!an! impairment! level,!Boutilier,! Sawatzky,!et!al.! found! that!use!of!a!Segway!can!reduce!spasticity,!decrease!pain!and!decrease!fatigue!on!a!shortRterm!basis.4!!!!Cerebral!palsy!is!a!neurodevelopmental!condition!beginning!in!early!childhood!and!persisting! through! the! lifespan.! “Cerebral! palsy! describes! a! group! of! permanent!disorders!of!the!development!of!movement!and!posture,!causing!activity!limitation,!that!are!attributed!to!nonRprogressive!disturbances!that!occurred!in!the!developing!fetal!or! infant!brain.!The!motor!disorders!of!cerebral!palsy!are!often!accompanied!by!disturbances!of! sensation,!perception,! cognition,! communication,! and!behavior,!by!epilepsy,!and!by!secondary!musculoskeletal!problems.”5!!!!Postural!control!is!the!process!of!balancing!a!multiRjoint!“inverted!pendulum”,!in!an!effort! to! keep! the! body’s! center! of!mass! (COM)! over! its! base! of! support! (BOS)! in!response! to! static! and! dynamic! disequilibrium.6,! 7! ! The! body! maintains! postural!stability,!in!response!to!environmental!changes!and!intended!interactions!and!tasks.!!Task! and! environmentRspecific! postural! stability! is! influenced! by! the! past!experience!of!the!patient!completing!the!balance!task,!the!patient’s!current!attention!to!a!task,!the!actual!task!being!undertaken,!and!the!environment!in!which!the!task!is!being!done.8R11!!!!Patients!with!CP!experience!high!anxiety!and!a!fear!of!falling!because!of!their!lack!of!inherent! postural! control.! ! This! results! in! decreased! exposure! and! practice! of!balance! demands,! except! within! the! confines! of! seated! mobility! or! gait! trainers.!!They! become! unfamiliar! with! the! demands! of! postural! control! and! balance.! ! To!explore! and! interact!with! the! environment,! an! “anchor”! for!purposeful!movement!and!helps!develop!functional!activity.12!!The!patient!with!poor!postural!control!has!poor! gross! motor! ability,! their! interactions! with! peers! at! home! and! in! the!community! is! limited,! their! access! to! fitness! and! recreation! decreases! and! their!overall!quality!of!life!suffers.13R15!!!!!Fell! and! Trommelen16! describe! several! aspects! to! a! motor! control! and! balance!training!intervention.!To!help!develop!anticipatory!control!and!postural!responses,!treatments!would!be!practiced! in! a!wide!variety!of! situations! and! settings,!with! a!wide!variety!of!postural! responses,! include!visual! feedback,!have!moving!surfaces,!and!be!a!self! imposed!intrinsic!movement!response.17R19!! !To!help!develop!stability!limits,! treatments! would! be! practiced! in! a! wide! variety! of! directions,! have! self!imposed!intrinsic!movement!response,!and!including!use!of!visual!feedback.20,!21!!To!encourage!greater!vestibular!system! function! treatments!would! focus!using!vision!



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and! gaze! stabilization! and! practicing! balance! on! a! variety! of! surfaces! and! uses! a!variety! of! lighting! circumstances.22! They! propose! that! task! specific! training!produces!greater!changes!in!impairments!and!function.!!Repetition!of!specific!tasks!must! be! useful! or! “meaningful”! in! terms! of! function! to! produce! “cortical!reorganization”!and!associated!meaningful!functional!improvements.!23,!24!!As!pediatric!and!adolescent!physical!therapist,!we!continually!strive!to!improve!our!balance! and!postural! control! treatment! options! to!help! young!patients!with!CP.25R32!! !Few!activities! simultaneously! challenge! the!perceptual! challenges!of!movement!through!space!and!postural!motor!components!of!balance!in!standing.!!The!Segway!was! chosen! as! a!modality! in! the! outpatient! setting! to! increase! the! child’s! interest!and!duration!of!practice!of!postural!control!and!balance!activities.!!Patients!with!CP!received!training!on!a!Segway!as!part!of!their!PT!plan!of!care.! !This!clinical!review!describes! patient! inclusion! considerations,! safety! concerns,! treatments,! and!outcomes!for!children!and!adolescents!with!CP!that!used!the!Segway!during!PT!for!balance!and!postural!control.!!Method:!!A$review!of!written!and!video!clinical!records!was!completed.!!!$

Participants:!This! is!a! clinical! review,!of!a! suburban!outpatient!multiRdisciplinary!pediatric!PT/OT/SLP!clinic.! !Patients!with!a!diagnosis!of!CP,!where!included!in!the!clinical!review!who!used!the!Segway!as!part!of!their!PT!plan!of!care.!Patients!were!already!receiving!PT!for!treatment!of:!!!

• Balance!and!Postural!Control!• Perception!Training!• ConstraintRInduced!Therapy!• Community!distance!ambulation!and!Functional!Mobility!training!• Strength!and!Tone!Management!

!There!were!17!patients,!6!females!and!11!males,!ranging!in!age!from!6!to!17!years.!!Mean!Age!was!9.6!years!old.!!CP!diagnosis!included$spastic!left!hemiparesis,!spastic!diplegia,!spastic!tripegia,!spastic!quadriplegia,!and!athetosis!with!a!variety!of!Gross!Motor! Function! Classification! System! (GMFCS)! levels! represented.33! ! For! further!demographic!information!see!Tables!1.!!! !



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Table$1$Patient$Demographics$!ID#$ Sex$ Age$ CP$Dx$ GMFCS$

Level$PMHx$ Orthotic$ Assistive$Mobility$

Device$

1! F! 8! L!Hemiparesis! 1! Heel!Cord!Serial!Casting! Left!AFO! None!2! M! 12! L!Hemiparesis! 1! Seizures,! UE! And! LE! Botox®,!

Visual!Perceptual!Impairment,!Hearing!Impairment!

Left! AFO,!Benik®! !wrist!splint!

!!None!

3! M! 9! L!Hemiparesis! 1! UE!Botox®! Left!AFO! None!4! M! 13! R!Hmiparesis! 1! Soft! Tissue! and! Bony! LE!

Surgery,! Seizures,! Perceptual!Impairment,! Processing!Delays!

Right! AFO,!Wrist/thumb!Benik®!splint!

None!

5! F! 17! Diplegia! 1! Soft! Tissue! and! Bony! LE!Surgery!

Bilateral!AFOs!

None!

6! M! 6! Diplegia! 3! Blind,! Seizures,! Significant!Developmental!Delay!

Bilateral!AFOs!

Rifton®! Gait!Trainer,! Bantam®!Stander,! Manual!Tilt!Wheelchair!

7! F! 7!! Diplegia! 3! Tracheostomy,! Visual!Impairment!

Bilateral!AFOs!

Kaye®! Posture!Control! Walker,!Manual!Wheelchair!

8! F! 8! Triplegia! 3! Soft! Tissue! and! Bony! LE!Surgery!

Bilateral!AFOs!

Kaye®! Posture!Control! Walker,!Adapted!Stroller!

9! M! 7! Triplegia! 3! ACC,! Seizures,! LE!Contractures,! Developmental!Delays!

Bilateral!AFOs!

Gator®! Rollator,!Manual!Wheelchair!

10! F! 11! Quadreplegia! 4! ITBP,! Spinal! Scolisosis! with!Rod! Fixation,! Knee!Contractures!

Bilateral!FRRAFO’s!

Rifton®! Gait!Trainer,! and!Evolve®! Stander,!Power! Tilt!Wheelchair!

11! M! 9! Quadreplegia! 4! LE! Botox,! Soft! Tissue! LE!Surgery,! CVI,! Expressive!Language!Delay!

Bilateral!SMO’s!

Rifton®! Gait!Trainer,! Manual!Tilt!Wheelchair!

12! M! 6! Quadreplegia! 5! Seizures,! Hypotonia,! LE!Contractures,! Visual!Impairment!

Bilateral!AFOs,! wristR!thumb!Benek®!splints!

Pony®! Gait!Trainer,! Bantam®!Stander,! Manual!Tilt!Wheelchair!

13! M! 10! Quadreplegia! 5! Seizures,! Visual! Impairment,!Hip! Dysplasia,! Cognitive!Delays,! LE!Alcohol!Block,! Soft!Tissue!LE!Surgery!

Bilateral!SMO’s!

Manual! Tilt!Wheelchair,!LiteGait®! Gait!Trainer!

14! M! 14! Athestosis! 1! Startle,! Hearing! Impaired,!Tremor!

Bilateral!UCBs!

None!

15! M! 9! Athestosis! 3! Soft! Tissue! LE! Surgery,!Hearing!Impairment!

Bilateral!FRRAFOs,!

Crocodile®! walker,!Drive! Assist!Manual!Wheelchiar!

16! M! 6! Athestosis! 4! Expressive! speech! delays,! LE!contractures!

Bilateral!AFOs!

Manual! Tilt!Wheelchair,! MKII!Hart!Walker®!

17! F! 12! Athestosis! 4! Expressive!Speech!Delay! Bilateral!FRRAFOs!

Manual!Wheelchair,!Rifton®! Gait!Trainer!

Abbreviations! Key:! PMHx=Past! Medical! History,! M=Male,! F=Female,! L=Left,! R=Right,! UE=Upper! Extremity,! LE=Lower!Extremity,! AFO=! Ankle! Foot! Orthosis,! SMO=Supramalleolar! Orthosis,! FRRAFO=Floor! Reaction! Ankle! Foot! Orthosis,! UCB= University!California!Berkley!Laboratories!Foot!Orthosis,!CVI=Cortical!Visual!Impairment,!ACC=Agenesis!of!Corpus!Collosum,!ITBP=Intrathecal!Baclofen!Pump.!$$



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Clinical$Equipment$Used:$The!Segway,!Model!i2!SE!was!used!by!the!participants34!(Table!2).$!Table$2$$Model$i2$SE$Specifications$Model!Specification*! Segway!i2!SE!Steering!Mechanism! LeanSteer**!Dashboard! InfoKey***!Max.!Payload!(Rider!Plus!all!Cargo)! 260!lbs!(117!kg)!!Max.!Speed:!! 12.5!mph!(20!km/h)!!Max.!Gradient!Limit! 15!degrees!Energy!(Rechargeable!Batteries)!! Saphion®!lithiumRion!!Battery!Pack!Weight!(pair)! 22.7! lbs! (10.3!kg)!Saphion®! lithiumRion!

batteries!Battery!Low!Temperature!Range! 14°!F!(R10°!C)!Range!on!a!Full!Charge! 16!to!24!mi!(26!to!39!km)!!Turning!Radius!! Zero.! The!wheels! can! rotate! in! opposite!

directions,!enabling!turning!in!place.!!Tire!Inflation!Pressure!! 15!psi!(1.03!bar)!!Power!Requirements!! 100!to!240!V~!(50!or!60!Hz)!!Machine!Weight!Without!Batteries!! 82!lbs!(37!kg)!!Ground!Clearance!(Unloaded)!! 3.4!in!(8.5!cm)!!Standing!Platform!Height! 8!in!(20.32!cm)!Machine!Length!and!Width!! 25.5!x!25!in!(65!x!63!cm)!!Handlebar!Height!from!Mat!! 38!R!43!in!(97!R109!cm)!!Handlebar! Height! from! Ground!(Unloaded)!!

46!R!51!in!(117R130!cm)!!

Powerbase!Height!(Unloaded)!! 8!in!(20!cm)!!Tire!Diameter!! 19!in!(48.3!cm)!!Tire!Type!! Standard!!Cost! 2015!$6,499!MSRP!*http://www.segwaysafety.com!!**The! LeanSteer! frame! and!handlebar! tilt! left! and! right! in! response! to! the! body’s!natural!inclination!to!lean!in!the!direction!of!intended!travel.!!***The!wireless! InfoKey! controller! constantly!monitors!data! such!as!battery! level,!speed!and!distance,!and!has!security!features.!The!InfoKey!is!used!to!set!limitation!on!speed,!allowing!for!present!speed!limitations!from!4!to!12!mph.!!The!InfoKey!also!allows!immediate!adjustment!from!full!(preRset)!speed!to!a!Turtle!mode!speed.!!!!Precautions$ and$ Safety:! The! following!precautions!were! taken!when! training!on!the!Segway.! !Staff,!parents,!and!patients!were! trained!and!alerted! to! the! following!safety!concerns!prior!to!initiating!training.!!(Segway,!Inc.!provides!additional!safety!training!videos!on!its!website.35)!!



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!Initial!Wobble!Precaution:!!For!patients!that!can!walk!on!their!own,!the!Segway!has!an! initial! front!and!back!wobble!when!you! first! get!on.! !This! is! explained!prior! to!anyone!getting!on.!!They!are!told!that!the!wobble!usually!lasts!about!5!seconds.!!It!is!essentially! the! Segway’s! sensors! and! computers! trying! to! match! the! patient’s!postural!control!and!balance.!!Once!they!get!into!“synch”,!the!wobble!goes!away.!As!a!precaution,!the!wobble!can!return!when!a!new!patient!is!learning!to!start,!stop!and!back! the! Segway! up,! even! at! slow! speeds.! ! Again,! the! Segway’s! sensors! are!responding!to!the!patients!postural!balance!reactions.!!It!takes!a!few!tries!to!get!that!smooth!and!for!the!wobble!to!go!away.!!Controlling! Creep!Precaution:! Assistants! and! parents! are! cautioned! to! control! the!Segway’s!position!by! tilting! the!bar! in! the! intended!direction.! !They!are!cautioned!not!to!put!foot!pressure!on!the!standing!platform!as!this!has!an!opposite!effect!on!stopping!or! controlling! its! creep.! !By! adding!pressure! to! the! front! of! the! standing!platform,! the!Segway!will! sense! its!outRofRlevel!position!and!will! try! to! level! itself.!Instead!of!moving!away!from!you,!it!moves!toward!you.!!This!is!the!normal!function!of!the!device!as!it!always!will!try!to!right!itself!to!a!level!position!by!speeding!up.!!In!effect,!it!pushes!the!attendant!backwards!until!they!stop!pushing!on!the!front!of!the!base!with!their!foot.!!Curb! Cut! Precaution:! ! Patients! that! have! never! moved! themselves! around! their!environment,! are! not! alert! to! environmental! barriers,! both! large! and! small.! ! A!common! thing! to!miss,! is! a! curb! cut.! !When! the!patient! starts! to! ride! the! Segway!themself!with!close!or!distant!supervision!(meaning!no!contact!guard!or!direct!gait!belt! support),! they! are! alerted! and! trained! to! watch! for! “curb! cuts”.! ! To! help!encourage!the!development!of!their!visual!scanning!of!the!environment!the!patient!tells! the! therapist! when! they! see! one! that! might! trip! them! up.! ! By! telling! the!therapist! when! they! see! them,! the! therapist! is! better! able! to! judge! the! patients!visual!scanning!and!attention!to!environment!barriers.!!Ice! and! Sand! Precaution:! ! As! long! as! the! Segway’s! two! wheels! are! on! similarly!textured!surfaces,!the!computer!and!sensors!are!able!to!maintain!its!balance.!!!Sandy!or! icy! terrain! are! high! caution! areas! as! the! Segway! can! stop! working! properly.!!Essentially! the!computers!become!confused!about! the!ground!beneath!and!cannot!provide!balance.!!!Pet!Precaution:!Pets,!on!or!off!a!leash,!are!not!allowed!around!the!patients!training!area,! as! this! creates! an!unpredictable! environment! and! situation! that! can!be!both!dangerous!to!the!patient!and!the!animal.!!“I!Can’t!Stop”!Precaution:!Some!patients!can’t!coordinate!shifting!their!weight!back!to!slow!the!Segway!down!at!moderate!or!faster!speeds.!!The!patient!panics!and!then!becomes! unable! to! help! themself.! ! No! patient! was! allowed! to! ride! alone! at! fast!speeds.!!Many!of!the!patients!asked!to!do!this!but!were!not!allowed.!!!



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!Racing! Precaution:! There! is! no! racing! allowed.! The! patient! losses! control,! losses!their!perceptual!awareness!of!distances!and!speeds,!and!are!pressured! into!taking!risks!beyond!their!postural!and!perceptual!ability.$!Other!Precautions:! !Patient’s!wore!a!bicycle!helmet!while!riding!the!Segway!alone.!!Patients! requiring! slight! assistance! or! more,! and! those! initially! using! close!supervision! wore! a! gait! belt.! ! ! The! gait! belt! was! monitored! for! dangling! and!shortened! to! avoid! catching! under! the!wheel,! as! this! could! pull! the! patient! down!toward!the!ground.! ! $The!treating!therapist!was!required!to!have!a!mobile!cellular!phone!on!their!person!at!all!times.!!Outdoor!areas!were!monitored!for!vehicle!traffic.!!Individual! caseRbyRcase! contingency! planning! was! reviewed! for! each! treatment!session!and!patient,!for!things!such!as!fatigue,!behavior,!psychomotor!readiness,!and!seizures.! ! Specifically! for! patients!with! seizure! disorders,! the! top! of! the! Segway’s!handlebar!was!padded!as!a!precaution!against!sudden!head!drop.$!PreZTraining$ Treatment$ Activities:! PreRtraining! treatment! activities! were!designed! to! determine! the! patient’s! static! and! dynamic! standing! balance! control!with! two!hands!on!a!bar! in! front! in!an!effort! to! replicate!standing!on! the!Segway.!!Decisions! were! made! as! to! their! levels! of! assistance,! standing! endurance,! safety,!psychomotor! learning! needs,! and! postural! control.! ! Examples! of! preRtraining!activities!include:!!

• SitRtoRstand!weight!bearing!with!ladder!support!in!front!• Use! of! uniRdirectional! and!multiRdirectional!wobble! board! in! standing!with!

ladder!support!in!front!• Tolerance!for!static!standing!in!standing!frame!with!decreasing!support!• Use!of!Lateral!Thigh!Trainer®!with!ladder!support!in!front!• Gait!training!with!walker!or!gait!trainer!• Use! of! LiteGait®! with! ladder! support! in! front! and! decreasing! vertical! lift!

assistance!(body!weight!support)!• Standing!on!platform!of!glide!swing!with!dowel!support!for!hands!!!• Curb!and!step!training!

!Progression$of$Assistance$Need$for$Mounting$And$Dismounting$the$Segway:!

• Patients!that!were!ambulatory!–!Assist!of!one!holding!the!Segway!handle!bar!and!stabilizing!its!movement.!!Patient!is!cued!to!step!up!like!their!stepping!up!onto! a! step.! ! Patient! is! encouraged! to! hold! the! Segway! handle! bar! before!stepping!up.!

• Patients!that!could!not!stand!or!walk!independently!R!Assist!of!two!with!one!holding!Segway!stable!while!the!other!assists!the!patient!to!step!up!and!on.!!Patient!is!encouraged!to!hold!the!Segway!handle!bar!before!stepping!up.!



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• Patients! that! required! knee! immobilizers! ! R! Patient! is! lifted! on! with!appropriate!assistance.!!Patient!is!encouraged!to!hold!the!handle!bar!as!they!stand!on!the!Segway.!

$Levels$of$Assistance$While$Using$the$Segway36:!!

• Independent:!No!patient!was!allowed!to!use!the!Segway!on!their!own!• Close!And!Distant!Supervision:!!Therapist!within!5!to!15!feet!of!the!patient!at!

all!times!• Slight!Assistance:!Contact!guard;!verbal!cues!• Minimal!Assistance:!Assist!of!one;!use!of!Theratogs®,!Spio®:!use!of!grip!assist!!• Moderate! Assistance:! Assist! of! one! or! two;! use! of! Theratogs®,! Spio®,! knee!

immobilizers,!grip!assist!!• Maximum!Assistance:! !Assist!of! two!or!three;!use!of!Theratogs®,!Spio®,!knee!

and/or!elbow!immobilizers,!grip!assist!!• Total!Assistance:!!No!patient!was!allowed!to!use!the!Segway!if!they!could!not!

bear!weight!through!their!legs!!Treatment$Activities:$

• Specific!courses!set!up!with!cones.!!This!was!similar!to!equine!barrel!racing,!weaving! around! various! cone! formations,! in! and! out! of! a! line! of! cones,!around!base!ball!diamonds,!etc.!(Figure!1!and!2)!Very!low!profile!color!cones!were!used!that!collapse!flat!when!ru!over!by!the!Segway!to!avoid!disrupting!the!patients!safety.!!

• Patient!selfRselected!destination!(“go!and!explore”,!“go!down!the!street!to!get!an! ice! cream”,! “go! around! the! block”,! “go! see! if! we! can! find! the! vending!machine”,!“Show!me!where!your!classroom!is”!etc.)!

• Indoor! and! outdoor! general! exploration! and! movement! around! the!environment.!!(around!the!room!or!building,!through!doors,!down!hallways,!along!sidewalks,!in!large!open!fields,!through!parking!lots,!etc.)!!!

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Figure!1!!Barrel!Racing!Illustration!!!!!!!

!!!!!

!!!!!!!$$$$$Figure$2$Weaving$Around$Cones$Illustration$$$$$$

$$$Reported$ Clinical$ Outcomes$ from$ use$ of$ Segway$ for$ Postural$ Control$ and$Balance$Training:!!Documentation! review! indicates! improved! motivation,! patient! participation,!duration! of! patient! practice,! decreasing! levels! of! assistance! and! access! to!community!based!activities.!!!Embedded!and!intrinsic!to!the!task!of!riding!a!Segway,!patients! were! able! to! move! about! and! explore! various! environments! in! standing!with!decreasing!levels!of!assistance!over!time!and!with!practice!(Table!3).!!!!!! !

START! END!

1s

3s

2s

4!



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Table$3$$Patient$Achievement$Toward$Less$Assistance$Over$Time$!! Patient!ID#! Patient!ID#! Patient!ID#! Patient!ID#! Patient!ID#!! Hemiparesis! Diplegia! Triplegia! Quadrepligia! Athetosis!Within! 5!minutes,! patient!was! able! to!use! the! Segway! with! close! to! distant!supervision.!

1!2!3!

5! ! ! 14!

After! 1! hour! of! training,! patient!continued! to! require! at! least! contact!guard!support!and!occasional!physical!assistance! for! steering,! acceleration!and!deceleration.!!!

4! 7! 8! ! !

Over!time,! !patient!was!able!to!control!the! Segway! with! decreasing! support,!but! never! without! at! least! minimal!assistance.!

! 6! 9!10!11!12!13!

16!

Following! at! minimum! 6! weeks! of!training,!patient!was!able!to!transition!to! close! supervision! use,! having!initially!required!moderate!assistance.!!!

! ! ! ! 15!17!

!Patients! learned! the! tasks! of! steering,! acceleration,! deceleration,! stepping! up! and!down.!!They!gained!exposure!and!practice!of!using!their!body!and!arms!in!response!to! the!perception!of! judging!distances.! ! They!used! their!hands! and!upper!body! to!maintain!balance! in!standing.! !Patients!were!able! to! increase!their!duration!of!use!from! bout! to! bout! as! improved! endurance.! ! One! patient! experienced! improved!handwriting! skills! and! control.! !One! speech! therapist! expressed! greater! hand! and!finger!control!when!accessing!augmentative!and!alternative!communication!device!(AAC).!Patients!were!able!to!experience!greater!exposure!to!socialization!and!peer!interaction!opportunities.!!!!Six! patients! were! able! to! use! the! Segway! outside! of! the! clinic! in! the! community!settings.! !Through!special!arrangement,!the!therapist!would!assist!and/or!train!for!these! community! activities! as! needed.! ! Documentation! review! indicated! the!following!examples!of!community!access!and!use:!!!

• At! school! during! middle! school! and! high! school! years! for! general! daily!community!distance!mobility!

• Attending!summer!academic!activity!at!university! campus! for!general!daily!community!distance!mobility!

• As! home! program! for! 1! month! with! parent! for! general! neighborhood!exploration!outings!and!general!exercise!

• During! bat! mitzvah! celebration! event,! rather! than! using! gait! trainer! or!adapted!stroller!

• At!middle!school!field!day!event!for!7th!graders!• During!physical!education!class!to!facilitate!participation!in!a!baseball!game!

with!peers!• During!a!walkathon!fundraiser!• During!AAC/AT!Summer!Camp!to!access!communication!stations!



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• Used! in! community! for! access! to! recreational! fields,! such! as! baseball!diamond,!accessible!rampedRplayscapes,!other!large!open!areas!

• To!access!neighborhood!streets!and!backyard!play!areas!• Before! school! to! facilitate! exercise! opportunities! in! a! gymnasium!

environment.!!!Discussion:$The!patients!that!were!included!in!this!review,!had!not!controlled!their!movements!through! space! with! intrinsic! postural! control! reactions! in! standing.! ! Mahncke!expressed! the! idea! that! problem–solving! inherent! in! doing! something! different! is!what! drives! neuroplasticity.37! Fell! encouraged! deliberate! focus! on! taskRspecific!practice!of!functional!skills!with!incorporation!of!principles!of!motor!learning!when!developing!balance!training!activities!for!patients!with!postural!control!deficits.16,!17!!The!cases!that!were!reviewed!demonstrated!naturally!selected,!and!age!appropriate!functional!tasks!to!participate!in!as!the!Segway!was!used!during!PT.!!!!Young!patients!with!CP!that!have!poor!balance!and!postural!control!have!difficulty!accessing! activities! that! challenge! the! motor! control! system! in! ways! that!incorporate!selfRimposed!intrinsic!movement!responses.! !Patton!and!Brown!used!a!body!weight!support!(BWS)!training!program!to!help!patient!safely!engage!in!whole!task! practice,! allowing! them! to! take! risk! without! fear! of! falling.! ! In! their! study!patients!practiced!an!extreme!and!demanding!version!of!the!whole!task!with!BWS!support,! resulting! in! improved!ability! to! complete! “less!extreme”! similar! task.38,!39!!The! Segway! similarly! offered! the! patients! a! safe! standing! platform! position! from!which! to! practice! the! demands! of! postural! control! responses! to! both! sensory!stimulation,!intentional!movement!and!environmental!interactions.!!At! times!postural!control!relies!on!sensory!systems,!such!as! the!body’s! location! in!space! and! the! body’s! movements,! including! visual! sense,! vestibular! sense,! and!somatosensory! experience! (combined! proprioception! and! tactile! sense).! ! This!sensory! information! is! conveyed! to! the! nervous! system! for! interpretation.! ! These!areas!of! the!central!nervous!system! include! the!posterior!parietal!area,! secondary!motor! cortex,! primary!motor! cortex,! cerebellum,! basal! ganglia,! brain! stem!motor!nuclei,! and! spinal! motor! pathways/circuits.40! ! In! response! the! musculoskeletal!system!makes! changes! in! the! body’s! position! through! reflex! reactions.! ! This! has!been! referred! to! as! a! “feedRback”! postural% response.! ! Postural! responses! are!triggered!by! sensory! input,! surface!movement!or! a!bump! to! the!body! resulting! in!motor! output! changes.! ! These! are! considered! distracted! postural! control,! or!subconscious! control! without! intent! or! purposeful! reactions! to! environmental!changes.41R43%!!At! other! times! the! patient!makes! intentional!movements! as! anticipatory! postural!control.!!These!are!responses!to!intended!interactions!and!tasks!to!keep!the!body’s!COM!over! its!BOS!for!static!and!dynamic!equilibrium.!This!has!been!referred!to!as!“feedRforward”! postural! adjustments! related! to! voluntary! movement.! ! These!



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postural! control! reactions!are! initiated!prior! to! the! start!of! the!movement.! !These!anticipatory! postural! adjustments! help! to! achieve! smooth! execution! of! desired!movements.11,!44R46!!!!Both!of!these!types!of!postural!control!response!(feedRback!and!feedRforward)!were!observed! as! the! patients! learned! to! control! the! Segway!more! independently.! ! For!instance!when!traveling!down!sidewalks,!a!typical!suspensory!balance!reaction!was!developed!by!one!patient! as! the! Segway! rolled!over!bumps.! ! Early! in! the! training!this!patient!would!either!collapse!at!the!knees!or!hold!a!ridged!reaction!to!the!bump!stimulus.! ! Gradually! a! more! typical! flexed! knee! and! hip! suspensory! reaction!emerged.! !Likewise,! feedRforward!postural!responses!developed!as!patients!gained!control! of! acceleration,! deceleration,! and! directionality! by! adjusting! their! body’s!posture! and! lean! on! the! Segway! as! they! moved! toward! and! around! their!environment!or!in!the!direction!of!their!intended!destination.47!!!!Further,! one!patient! used! the! Segway! to! push! a! large! folded! gym!mat! around! the!gymnasium! floor! to! setRup! an! obstacle! course.! ! Many! of! the! patient’s! learned! to!adjust! their! postural! lean! to! control! tighter! negotiation! of! a! barrel! race! course! or!move!inRandRout!of!cones!(Figures!1!and!2).!!Gradually!the!patients!would!learn!how!to! anticipate! distance,! speed! and! turning! radius! and! make! adjustments! to! their!posture!to!control!the!Segway!for!faster!completion!of!the!course.!!Patients!learned!to!anticipate!greater! lean!forward!or!backwards!to!control!negotiation!of!hills.! !To!climb!a!hill,!the!patient!needs!to!lean!forward!with!greater!force!to!achieve!forward!movement,!and!lean!backwards!to!slow!descent!when!going!down.!!These!examples!illustrate! conscious! attention! to! environmental! changes! and! intended! actions!resulting!in!concerted!motoric!postural!changes!to!be!successful!with!their!balance!control.!!!We! recognize! that! postural! control! and! balance! is! complex! and! there! are! many!varying! contributing! influences! on! the! body’s! success! to! respond! to! sensory,!intended,! and! environmental! information.! ! ! SelfRcontrol! of! acceleration! and!deceleration! actions! for! response! to! environment! may! also! be! related! to! greater!visual! perceptual! response! reactions.! ! Kandel! et! al.! found! that! vision! provides!information! about! the! environments! vertical! alignment! and! the! body’s! motion!relative!to!the!environment,!providing!information!about!when!the!body!will!make!contact!with!objects!in!the!environment.48!!!When!studying!the!fear!of!falling,!and!its!relationship!to!balance!control,!Carpenter!et!al.!noted!that!stimuli!to!the!vestibular!system! may! evoke! postural! reflexes! inherent! in! balance.49! ! Further,! Peterka!discussed! that! the! vestibular! system! is! thought! to! detect! deviation! of! head!orientation! with! respect! to! the! field! of! gravity,! called! the! graviceptive! signal.50!!Vestibular! sensory! signals! are! considered! to! be! the! primary! contributor! to!graviception.51!!!In!an!effort!to!match!ICF!proposed!framework,!plans!of!care!for!young!patients!with!CP! are! challenged! to! consider! the! patient’s! functioning! at! the! level! of! body,! the!



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whole! person,! and! the!whole! person! in! a! social! context.! ! The! ICF! uses! the! terms!capacity! and! performance! qualifiers.! ! The! “capacity! qualifier! describes! an!individual’s!ability!to!execute!a!task!or!an!action”!and!the!“the!performance!qualifier!describes!what!an!individual!does!in!his!or!her!current!environment”.!!Clinic!based!treatment! activities! often! fall! short! of! satisfying! both! performance! and! capacity!qualifiers,!due!to!the!clinic!not!representing!real!home!or!community!environment;!or! the! home! not! providing! impairment! level! modalities! or! interventions.!!Treatments! and! interventions! that! can! span! the!health! condition,! the! impairment,!the! activity! limitations! and! participation! restrictions! are! rare,! and! often! do! not!encompass!the!whole!“biopsychosocial”!model.52! !Six!of!the!patients!in!this!clinical!review,!that!were!able!to!use!the!Segway!in!the!clinic!had!strong!interest!in!gaining!access!to!its!use!in!the!community,!bridging!the!benefits!of!gained!postural!control!for! standing! mobility,! and! improved! efficient! access! to! activity! and! recreation!participation.!!!Clinical$Review$Limitations:!!This!clinical!review!has!several!limitations.!!As!a!clinical!review,!biases!are!present.!!As!a!single!site!study!we!were!only!sampling!one!clinics!experience!resulting!in!bias.!!However! we! are! not! aware! of! the! Segway! being! used! as! a! postural! control! and!balance!training!device!in!other!clinics.!!Patients!were!selfRselected!from!our!limited!patient!caseload!and!there!may!be!others!that!could!benefit!from!its!use.!!There!is!a!lack!of!specific!assessment!tools!for!preRpost!comparison,!such!as!use!of!the!TimedRUpRandRGoRTest! (TUG)53R55;! Pediatric! Balance! Scale56;! p0ediatric! and! patient! and!family! ! questionaires57R59;! GMFM60;! segmental! assessment! of! trunk! control!(SATCo)61,!62;!WeeFIM63,!64;!or!Early!Clinical!Assessment!of!Balance!(ECAB).65!!Conclusions:$$$This! clinical! review!supports! the!use!of! a! Segway! for! treatment!of! young!patients!with!CP!during!PT! for! the! treatment!of!postural!control!and!balance.! !This!clinical!review!also!suggests!that!the!Segway!can!be!used!in!a!variety!of!community!settings!and!situations!to!assist!mobility!for!adolescents!with!CP.!Further!research!is!needed!to! better! understand! how! the! Segway! affects! patients! with! postural! control! and!balance!deficits!due!to!CP.! !More!rigorous!research!is!needed!to!better!understand!the!functional!and!clinical!outcomes!gained!from!the!use!of!the!Segway!during!PT.!!This! clinical! review! is! a! good! example! of! the! links! needed! between! realRworld!clinical!treatment!environments!and!the!research!setting66R70.!!!!References:$1. Segway!technology.!http://www.segway.com/aboutRsegway/segwayR

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Use$of$the$Segway$During$ Physical$Therapy$for$ …iss.pitt.edu/iss2015/ISS2015Handouts/PS5.3_Handouts.pdf · Use$of$the$Segway$During$ Physical$Therapy$for$ Postural$Control$and$Balance$